Aetna Insurance

I'm trying to upgrade my CPAP to the Resmed S9 Autoset and the DME is saying my insurance only covers Intellipap ..... anyone have experience with this or suggestions on how to proceed?

Thanks,

Ryan

Call your insurance and ask them what it covers and if it covers the S9 find another DME.

I bet your DME only stocks the Devilbiss machines which is what the Intellipap is.
Find another DME that stocks ResMed machines.

Insurance companies don't specify the brand. They could care less unless you happen to be a part of some HMO thing.

just called insurance and they looked up and said that is what is covered ..... i need to get a Predetermination Benefits Request from my Dr. explaining why the S9 would be the better machine then they review and make a decision. DME is Lincare and they carry S9 Autoset.

May make more sense to go out of pocket for the machine online and not jump though all the hoops to get denied in the end anyway.

Any recommendations on good priced, reliable online retailers?

Our host CPAP.com

Most CPAP related items I have was purchased by myself mostly here at the host but I did get health insurance last year through my wife's employment and it is with Aetna. I went through every DME on the in network list but they don't want to deal with Aetna and want to give you old machines. After months one DME ordered what I wanted, unfortunately they wont even get me filters now but my 1000.00 deductible starts over in January so I will be buying them on my own again anyway. The DME did bill Aetna for the machine I wanted and Aetna did pay without issue at 80% since I had met the deductible. I was prescribed BiPAP but I don't need BiPAP and if I need another machine I would save money by buying a CPAP from the host out of pocket than what the 20% cost me going through insurance and the DME.

I don't know the details but I heard yesterday (from a DME owner) that Aetna had just reduced some of the payments they make to DMEs for some supplies, as of last month. I don't know if this extends to cpap machines or if it is just masks and other supplies.

Houli wrote:just called insurance and they looked up and said that is what is covered ..... i need to get a Predetermination Benefits Request from my Dr. explaining why the S9 would be the better machine then they review and make a decision. DME is Lincare and they carry S9 Autoset.

Does your prescription specify a range of pressures? Sometimes they use this as an excuse to deny an Auto machine.

Is Lincare your only in-network DME choice?

The prescription is approved for APAP (range 5-20). Lincare is the only "local" in-service provider ..... anyone have recommendations in the Washington DC Metro area (i'm in Reston, VA).

Thanks.

Houli,

First question is whether your Aetna plan is an HMO plan or Medicare Advantage (also known as Medicare Part C)?

If either of those is the case, then you may be limited to a particular brand and model of machine by your HMO. But the only way to be certain is to call Aetna and find out for sure.

If it's not an HMO or Medicare Advantage plan, then you need to call and find out exactly how they reimburse CPAP machines. Please see "What you need to know before you meet your DME" in my signature below, it will explain.

Most insurers reimburse by HCPC's (billing codes) and ANY E0601 machine is covered, cheap brick to s9 Autoset. If it's you traditional Medicare (A & B) supplement that's absolutely the case, most private insurers follow suit.

How long have you had the Intellipap? Lincare is going to be very reluctant to swap out a now used inexpensive Dvlibiss for a very exepnsive S9, so it's going to take a lot of work. If you've had the Intellipap for a while, you're basically SOL.

Randy said:
“I don't know the details but I heard yesterday (from a DME owner) that Aetna had just reduced some of the payments they make to DMEs for some supplies, as of last month. I don't know if this extends to cpap machines or if it is just masks and other supplies.”

This should not matter to the patient. If the DME is contracted to provide the supplies at the Aetna rate, then the DME has to provide the supplies. If they don’t want to provide supplies for less money, the DME has the option of not contracting with Aetna. In 99% of the cases, they may NOT charge the patient one penny more. See “Don’t Pay that Upcharge”.

You could try Baystate Medical. I have had good success with them with getting a data capable auto machine with straight cpap pressure and now an S9 Autoset.

DJ

I do not have an IntelliPap - my current machine is a 10 year old S7 Lightweight that i would like to upgrade. My insurance is through my wife's plan at Lockheed Martin. Aetna has said they treat CPAP machines as a lease agreement so you never actually own the machine. I would have to pay my deductible ($650) and they cover 85% after that. THere is an annual maintenance fee and i would need to pay for supplies up to the deductible again in 2012. They didn't have an answer when i asked why they only cover one machine ... any way you recommend rephrasing this?

Thanks.

I do recall my insurance person asking for a code and I didn't have this. Is E0601 the correct code for S9 Autoset? Maybe I'll call back with this added info.

Houli wrote:I do not have an IntelliPap - my current machine is a 10 year old S7 Lightweight that i would like to upgrade. My insurance is through my wife's plan at Lockheed Martin. Aetna has said they treat CPAP machines as a lease agreement so you never actually own the machine. I would have to pay my deductible ($650) and they cover 85% after that. THere is an annual maintenance fee and i would need to pay for supplies up to the deductible again in 2012. They didn't have an answer when i asked why they only cover one machine ... any way you recommend rephrasing this?

Thanks.

If they were to bill as a rental (most are 10 months) you would probably pay most of that out of pocket if your deductible has to be met first, unless you have a lot of other medical expenses that will use up that $650 deductible...

If they bill out rental at around $150/month for 10 months, you would pay whatever the Aetna contracted price is for rental (many insurances allow at least $70-80 of that charge under E0601). So your outlay could be $70-80 per month for the rental until you meet your deductible with other medical costs.

Anyway, if you figure that the S9 Autoset + heated humidifier retails for around $1,050 and they stand to collect a total of around $800 from you over 10 months, this is the roadblock that most of us come up against with the DME when we ask for the S9 Autoset. I'm guessing that a brick & mortar DME gets it for a bit less than that retail figure, but even if they get it for 20% less you can see why they are reluctant. That is why they try to push the Intellipap or some other machine they can make money on.

If I had a $650 deductible to meet first, I would consider looking out for a used S9 Autoset with low hours - call DMEs to see if they have any returns due to non-compliance. Maybe you can find one for less than your deductible.

secondwindcpap.com is another source for gently used machines.

That sounds familiar. Before telling me the S9 was not covered by insurance the DME said it would be $255 up front with $48/month for 9 months (total $687). If yours is a "lease agreement" as well - in your experience what are the on going maintenance fees etc with your arrangement? Do you find this to be more beneficial then owning outright?